Arterial Leg Ulcer Clinical Pathway

Transcription

1 Waterloo Wellington Integrated Wound Care Program Evidence-Based Wound Care Arterial Leg Ulcer Clinical Pathway 0-7 Days Expected Outcomes Notes Most Responsible Physician(MRP)/Nurse Practitioner (NP) identified/informed Refer patient to Care Connects if no responsible practitioner currently involved with patient Determine if MRP/NP is part of Family Health Team (FHT) or Community Health Centre (CHC) and consider additional supports available Medical/surgical history and co-morbidity management considered within care plan Medication reconciliation and their impact on wound healing reviewed Risk factors include: Smoking Diabetes mellitus Hyperlipidemia Hypertension Coronary artery disease History of cerebral vascular accident (CVA) Low hemoglobin Obesity Poor nutrition Decreased thyroid function Psoriasis Autoimmune diseases Chronic renal disease Congestive heart failure Impaired liver function Use of systemic steroids, immunosuppressive and chemotherapy >70 years of age Age years with history of diabetes or smoking < 50 years with diabetes and one other atherosclerotic factor History of vascular surgery or deep vein thrombosis Bleeding disorders Family history of arterial disease Prescription, non-prescription, naturopathic and illicit drug use (including e-cigarettes, inhaled substances and nicotine replacement therapy) Medications that can affect healing include: chemotherapy, anticoagulants, antiplatelets, corticosteroids, vasoconstrictors, antihypertensives, diuretics and immunosepressive drugs Other medications used to treat acute episodic illnesses may affect healing (eg. antibiotics, colchicine, anti-rheumatoid arthritics) Vitamin and mineral supplementation Recent blood work and diagnostic test results reviewed and Determine bloodwork implications for wound healing considered Blood Sugar, if patient is Diabetic A1C, if patient is Diabetic Albumin CBC Kidney Function Colesterol level Any diagnostic tests done previously i.e: Vascular Segmental Studies, UltraSound Doppler Waterloo Wellington Integrated Wound Care Program Arterial Pathway Feb

2 Patient s nutritional status optimized Calculate Body Mass Index (BMI) Determine recent weight loss/gain Review blood work results Complete Mini Nutritional Assessment (MNA) If screening section results < 11 = complete assessment section If Assessment section results < 24 = Registered Dietician referral required Physical assessment performed Baseline blood pressure, pulse and respiration Baseline weight and height, BMI Wound and periwound assessment completed Arterial Wound Characteristics 4 P s of Arterial Ulcers Pale wound base Punched-out appearance Painful Parched (low to no exudate) Measure and document size of wound using the following reliable tool: Bates-Jensen Wound Assessment Tool (BWAT) OR Leg Ulcer Measurement Tool (LUMT) Determine wound etiology Arterial ulcers are typically pale at base of wound, have punched out appearance, are more painful than expected and have low to no exudate Results of LLA and ABPI/TBPI Assessment for infection NERDS Any 3 or more of the following indicate HIGH superficial infection STONEES - Any 3 or more of the following indicate HIGH superficial infection in deep compartment (Require Urgent Medical Attention) Obtain photos following best practice as per framework for individual organization policies and procedures. Suggest following publication as guideline: Pain management considered and initiated Pain Red Flags Possible Infection Increase in pain level (new pain in patients with altered sensation ) Possible Arterial Involvement Pain on walking (caused by intermittent claudication) Pain with elevation of lower limbs Rest pain Nocturnal pain Use 0 10 Numeric Pain Rating Scale No Moderate Worst Pain Pain Possible Pain Arterial pain is typically described as: Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication) Identify and document type of pain 1. Neuropathic Pain (described as burning, stinging, shooting, stabbing or hyperesthesia sensitivity to touch). Suggested pharmaceutical treatment: Second generation tricyclic agents e.g. Nortriptyline or Desipramine. If pain is not relieved try using Gabapentin or Pregabalin. Waterloo Wellington Integrated Wound Care Program Arterial Pathway Feb

3 Acute arterial occlusion is a life and limb-threatening situation which requires immediate emergency intervention especially if there is sudden or severe pain 2. Nociceptive Pain (described as sharp, aching or throbbing). Suggested pharmaceutical treatment: Non-Opioids e.g. ASA or Acetaminophen Mild Opioids e.g. Codeine Strong Opioids e.g. Morphine or Oxycodone Obtain MRP/NP orders for pharmaceutical treatments (opioids and non-opioids) Non-pharmacological pain control options Bilateral lower leg assessment (LLA)completed Right ABPI/TBPI: Highest Right Ankle/Toe Pressure = Highest Brachial Left ABPI/TBPI: Highest Left Ankle/Toe Pressure = Highest Brachial Assess for Signs and symptoms of Peripheral Arterial Disease (PAD): Pain with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication) Dependent rubor in lower legs and feet Pallor in feet on elevation Dry, shiny skin on lower legs Edema subsequent to leg being dependent Thick or flaking toe nails Hairless lower legs and feet Weak or absent pulses Intense hyperesthesia (sensitive to light touch) Limb muscle may appear wasted from ischemic atrophy Delayed capillary refill Distal gangrene Non-healing wound Lower Limb Assessment Completed Complete ABPI/TBPI If ABPI/TBPI completed within last 3 mths, results must be obtained If unable to obtain ABPI/TBPI, referral to medical imaging for Vascular Segmental Studies is recommended Referral to Vascular Surgeon as soon as Vascular Segmental Studies result is available. Repeat ABPI/TBPI assessment every 3 months if healing is not progressing Assess pulses (popliteal behind knee, dorsalis pedis top of foot, posterior tibial medial ankle) Correct Outcome Based Pathway Confirmed Wound etiology and appropriate pathway established Confirm wound etiology Arterial ulcers are typically pale at base of wound, have punched out appearance, are more painful than expected and have low to no exudate Results of LLA and ABPI/TBPI Identify initial cause of wound Waterloo Wellington Integrated Wound Care Program Arterial Pathway Feb

4 Peripheral Arterial Disease (PAD) (see guidelines for PAD) ABPI 0.5 to 0.8 TBPI 0.64 to 0.7 Suggest Transcutaneous Oxygen Pressure (TcPo 2), Laser Doppler Flowmetry, Doppler Arterial Waveforms or Segmental Doppler Pressure studies ABPI <0.5 TBPI <0.64 Urgent vascular surgical consult needed Results of lower leg assessment (LLA) Results of ABPI/TBPI Results of wound assessment Vascular Segmental Studies results If etiology is still unknown, referral is needed for wound Care lead or ET. Referral For Vascular Assessment Initiated/Completed Communication with MRP and/or Nurse Practioner to update on any significant changes in patient s condition or the outcome of the assessment. Referral to Vascular Surgeon as soon as Vascular Segmental Studies result is available. Acute arterial occlusion is a life and limb-threatening situation which requires immediate emergency intervention Signs and symptoms that may become severe may be associated with the following: Pale or blue skin Skin cold to the touch Sudden decrease in mobility No pulse where one was present prior to this Wound treatment plan determined in accordance to treatment goal (healable, maintenance or non-healable) Caution: USE DRY WOUND HEALING 1. Keep eschar dry 2. No occlusive dressings 3. Do NOT debride 4. Avoid tourniquet effect when securing dressings 5. If eschar becomes wet/boggy URGENT referral to advanced wound care specialist is recommended Wound Therapy Initiated Arrange for MRP/nurse practitioner orders as required to begin plan of care including agreeance to professional referral recommendations Identify any potential barriers to wound treatment plan Utilize toolkit to determine wound cleansing, debridement and dressing selection South West Region Wound Care Program Wound Cleansing Table and Dressing Selection and Cleansing enablers CAWC Product Picker chart CAUTION: When Using Compression Compression is typically contraindicated in the presence of peripheral arterial disease. In some circumstances light compression may be beneficial, but only if arterial supply is sufficient. Sufficient arterial supply should be objectively evidenced by diagnostic tests. In such cases, compression should be ordered by an advanced wound care physician or nurse practitioner only. Compression therapy history documented: Previous compression garments Age of compression garments Waterloo Wellington Integrated Wound Care Program Arterial Pathway Feb

5 Adherence Application and removal of compression in past Finances Reason compression treatment plan has changed if applicable Patient and caregiver concerns and goals integrated into the care plan and shared with care team Patient Discharge Planning Initiated For Patient Independence And Prevention Cardiff Wound Impact Questionnaire OR World Health Organization Quality of Life (WHOQOL) form Ensure all patient/caregiver goals and concerns been addressed Patient counselled on the benefit of comfort measures Personal assistance available to perform activities of daily living Safety of transfers Recommendations for exercise to decrease claudication if tolerated Consider Occupational Therapist referral for comfort measures Encourage patient to sleep in bed with no lower limb elevation (most arterial pain increases when feet elevated above heart level) Mobility and dexterity aids currently being used Coping strategies implemented into plan of care Patient s concerns and fears Signs of anxiety or other mental health issues (eg. delusions, hallucinations, paranoid behaviour) Depression screen using Geriatric Depression Scale assessment form GDS15 Suicide assessment if applicable ETOH and illicit /recreational drug use Family and caregiver support identified and incorporated into plan of care Social supports/communityresources currently utilized is integrated into plan of care Family/caregiver actively able to participate in treatment plan Family support Community resources Respite and Adult Day Program Private insurance availability Eligibility for Assistive Devices Program, ODSP, High-needs fund, Veterans Affairs Canada or Aborignal Services Confirm that ongoing medication coverage is arranged Link to Trillium Drug Benefits Professional referrals are initiated Ensure referrals done according to patient s needs Refer to guideline for list of health care professionals Waterloo Wellington Integrated Wound Care Program Arterial Pathway Feb

6 Consider referrals to ET/Wound Care Lead if required to ensure appropriate treatment plan Days Expected Outcomes Notes Reassess, measure and document size of wound. Calculate the percentage of healing 20 30% reduction in wound size Measure and document size of wound Bates-Jensen Wound Assessment Tool (BWAT) Complete BWAT score at each visit Re-assess for infection at each visit (arterial wounds are at high risk of infection) NERDS Any 3 or more of the following indicate HIGH superficial infection STONEES - Any 3 or more of the following indicate HIGH superficial infection in deep compartment (Require Urgent Medical Attention) Obtain photos following best practice as per framework for individual organization policies Percentage of Healing (Cacluated from the initial visit) Calculation: The two most important points are that measurements are done weekly, and using a standardized method within each organization. V (Initial) V (Current) x 100 = % reduction in volume V (Initial) (V = volume of wound calculated as Longest Length x Perpendicular Widest Width x Depth straight in) (Adapted from Sussman and Bates-Jensen 2007) Consider required referrals to ET/WCS/MRP/Surgeon/NP and further follow-up with previous professional referrals if healing percentage is not achieved Wound Therapy Reassessed Utilize toolkit to determine wound cleansing, debridement and dressing selection (South West Region Wound Care Program: Wound Cleansing Table and Dressing Selection and Cleansing enablers and CAWC Product Picker chart) Review the Treatment Plan Review pain level with elevation of lower limbs, rest pain, nocturnal pain and pain on walking (caused by intermittent claudication) Review medical/surgical history and co-morbidity management for changes Review medication for changes Review recent blood work, diagnostic test results and home gylcaemic control Review recent dietary consult if applicable identify need for debridement (in presence of good arterial supply) Chronic Disease Self- Management Plan Initiated Chronic Disease Management Client and caregiver appropriate for selfmanagement Identify any potential barriers Waterloo Wellington Integrated Wound Care Program Arterial Pathway Feb

7 Review adherence to the plan Resources in place for self-management Patient/caregiver educational plan initiated Patient/caregiver educational plan initiated Emergency signs and symptoms of Peripheral Arterial Disease (PAD) that require immediate Compression is typically contraindicated in the medical attention presence of peripheral arterial disease. In Risks of compression therapy some circumstances light compression may be Smoking cessation including e-cigarettes and nicotene replacement beneficial. In such cases, compression should Glucose control therapies be ordered by an advanced wound care Weight control physician or nurse practitioner only. See Pain Management algorithm in guidelines. Self management of wound care Reduce risk of an infection Diagnostic vascular testing Vascular surgery: revascularization Graduated walking program Prevention of injury avoid extremes (hot/cold, caffine, loose/tight garments) When to call primary care giver (eg. signs and symptoms of infection, deep vein thrombosis, cellulitis, impaired blood flow) Limb preservation Community support groups Ability to self-manage optimized Barriers to participate in self care transportation, socioeconomic, social environment, other co-morbidities) Cognitive ability to self manage care Review importance and potential barriers to smoking cessation at every visit Hygeine to prevent infections Environment Wound care Compression application and removal if prescribed Daily exercise Days Expected Outcomes Notes Wound is closed by 12 weeks Ensure wound is closed. Encourage client to control factors that lead to arterial disease Smoking cessation Blood pressure regulated Cholesteral controlled Report any signs and symptoms of leg/foot pain to physican/np/vascular surgeon Promote exercise and diet If wound is not closed, move to most appropraite pathway i.e: Maintenance Pathway or Nonhealing Pathway Waterloo Wellington Integrated Wound Care Program Arterial Pathway Feb